The rules in place for preventing Medicare fraud before it starts are cumbersome and inadequate, particularly when it comes to healthcare sectors that have been identified as "low-risk," according to the Wall Street Journal.
The article points to a recent case involving John and David Mkhitarian--cousins who created 70 bogus laboratories, clinics and physician practices, and used the stolen identities of physicians to submit $3.3 million worth of fraudulent Medicare claims over two years. Although the Mkhitarians were eventually caught, the case exemplifies the shortcomings within the Medicare system to adequately identify and prevent these types of fraud schemes before they begin. Because inspectors are not required to visit providers with lower risk of fraud and abuse, the Mkhitarians were able to submit false claims undetected.
Some say that preventing persistent fraud problems would require a complete overhaul of the system through an act of Congress, which is unlikely. According to the WSJ, tighter screening of medical providers and ejecting bad actors more rigorously are two steps that the Centers for Medicare & Medicaid Services could take on its own. In December, CMS issued a final rule that provides greater discretion in detecting fraud and removing "individuals that pose a program integrity risk to Medicare."
However, the lack of fraud prevention resources at CMS makes it difficult to catch potential fraudsters before it's too late. More than 45,000 new providers enroll ever month, and CMS is forced to balance fraud prevention with access to medical care. Since 2011, CMS has required fingerprints from providers of home healthcare and durable medical equipment, but the agency has been forced to focus on those high-risk providers, leaving other areas vulnerable to fraud. Furthermore, officials say inspecting every provider would be "impractical."
Ryan Stumphauzer, former head of the Medicare Fraud Strike Force in Miami, tells the WSJ that basic screening practices, similar to the way drivers are tested before receiving a license, would be a step in the right direction.
"Why not perform this type of common-sense screening before handing out Medicare billing privileges?" he told the newspaper. "Ask basic questions: Does the applicant have education, training or experience in health care? Are they versed in basic Medicare rules and regulations?"
Additionally, CMS has been slow to take action on providers with a criminal history. In 2011, two senators sent CMS a list of 34 providers that still had Medicare billing privileges despite a criminal record of felonies such as healthcare fraud and tax evasion. Later, the senators pointed to Conrad Murray, Michael Jackson's personal physician, who remained eligible for Medicare billing despite a conviction of involuntary manslaughter and a suspended medical license.
- read the WSJ article